2024/2025 with elaborated
questions and answers
A client develops internal bleeding after abdominal surgery. Which signs and symptoms
of hemorrhage should the nurse expect the client to exhibit? Select all that apply.
1
Pallor
2
Polyuria
3
Bradypnea
4
Tachycardia
5
Hypertension - CORRECT ANSWER 1, 4
What is the term for shock associated with a ruptured abdominal aneurysm?
1
Vasogenic shock
2
Neurogenic shock
3
Cardiogenic shock
4
Hypovolemic shock - CORRECT ANSWER 4
A client who has peripheral arterial disease of the lower extremities tells the nurse, "I
walk so slowly that no one wants to walk with me." What is the best response by the
nurse?
1
"A vascular rehabilitation program may help you."
2
"You should be sitting with your feet elevated, not walking."
3
"Try again tomorrow because maybe you will have a better day."
4
"They are not good friends if they are not willing to walk with you." - CORRECT
ANSWER 1
,The nurse notes asystole on the cardiac monitor. Which action should the nurse take
immediately?
1
Defibrillate
2
Assess the client's pulse
3
Initiate advanced cardiac life support
4
Check another lead to confirm asystole - CORRECT ANSWER 2
One week after admission to the cardiac care unit, a client displays an outburst of anger
and tells the nurse to get out of the room. Which is the most appropriate nursing action?
1
Administer the prescribed sedative.
2
Return when the client has calmed down.
3
Point out that this behavior is inappropriate.
4
Notify the primary healthcare provider of the client's behavior. - CORRECT ANSWER 2
Which clinical indicator is the nurse most likely to identify when completing a history and
physical assessment of a client with complete heart block?
1
Syncope
2
Headache
3
Tachycardia
4
Hemiparesis - CORRECT ANSWER 1
The family of a client with right ventricular heart failure expresses concern about the
client's increasing abdominal girth. What physiologic change should the nurse consider
when explaining the client's condition?
1
Loss of cellular constituents in blood
2
Rapid osmosis from tissue spaces to cells
3
Increased pressure within the circulatory system
4
Rapid diffusion of solutes and solvents into plasma - CORRECT ANSWER 3
, A nurse in the coronary care unit (CCU) identifies ventricular fibrillation on a client's
cardiac monitor. What intervention is the priority?
1
Elective cardioversion
2
Immediate defibrillation
3
An intramuscular (IM) injection of digoxin
4
An intravenous (IV) line for emergency medications - CORRECT ANSWER 2
A nurse is caring for a client who was admitted to the hospital with a diagnosis of
chronic obstructive pulmonary disease and is receiving oxygen at 2 L/min via nasal
cannula. What is the primary focus of therapy when caring for this client?
1
Limiting hydration
2
Improving ventilation
3
Decreasing exogenous oxygen
4
Correcting the bicarbonate deficit - CORRECT ANSWER 2
A client with a history of rheumatic fever and a heart murmur reports gaining weight in
spite of nausea and anorexia. The client also reports shortness of breath several times
each day and when performing minor tasks. Which additional information should the
nurse obtain?
1
Retrospective 24-hour calorie count
2
Elimination pattern during the last 30 days
3
Complete gynecological and sexual history
4
Presence of a cough and pulmonary secretions - CORRECT ANSWER 4
A client is admitted to the hospital with a diagnosis of laryngeal cancer. What is a
common early sign of laryngeal cancer for which the nurse should assess in this client?
1
Aphasia
2
Dyspnea
3
Dysphagia
4
Hoarseness - CORRECT ANSWER 4